Elizabeth DeVos MD, MPH, FACEP,University of Florida College of Medicine—Jacksonville
Editor: Nur-Ain Nadir. MD, University of Illinois College of Medicine—Peoria
A 53 year-old male presents to the Emergency Department triage desk, dropped off by his brother who found him sitting in the garage with a gun. The patient lost his job today and had been having increasing fights with his children after a recent divorce. He has been drinking more heavily though is not currently intoxicated. On assessment, the patient admits to the triage nurse that he was considering suicide but really would like to go home now. His vital signs are HR 110, BP 118/76, RR 18, SpO2 98% RA, Temperature 98.4 F. He is placed in a monitored area and changed into hospital scrubs. A psychiatric hold is ordered by the attending when he attempts to leave.
Upon finishing this module, the student will be able to:
Identify situations in which suicidal risk assessment is required.
Discuss the components of a psychiatric oriented history and physical.
Discuss appropriate risk stratification for suicidal patients and limitations of prediction instruments.
Recall components of a follow-up plan for suicidal patients not admitted to the hospital.
Emergency providers have the duty to recognize and provide care for patients who attempt to harm themselves or to commit suicide. After an attempt at self-harm, the risk of another event increases. In fact, the risk of suicide increases 600% after a single ED presentation for self-harm. Further, many patients presenting with non-psychiatric complaints have depression and up to 10% may have suicidal thoughts. Stressors contributing to self-harm include relationship concerns, socio-economic difficulties, loneliness and mental illness.
Initial Action and Primary Survey
The primary goal is to assure safety of the patient and staff. Evaluate ABCs with specific attention to toxidromes or injuries (including cervical spine protection). A full medical exam is indicated in the presence of abnormal vital signs.
Remove any weapons or potential toxins from the patient and ensure that the patient has continuous, direct observation. In the history, utilize a non-judgmental tone to identify the extent of any injuries and ingestions. Ask questions empathetically and directly to assess what happened and the surrounding circumstances and psychiatric history, preferably utilizing open-ended questions. Determine amount and time of any ingestion. Elicit whether the patient has an ongoing intent to harm him or herself. Utilize collateral history from any family, friends or rescue personnel present.
Patients may present as victims of overdose or injury either by private vehicle or in the custody of police or rescue personnel. Patients should be examined for signs of injury including burns, ligatures, gunshot wounds, lacerations and fractures. Also consider intoxication, acute psychosis or acute medical condition precipitating the presentation. Look for any specific toxidromes.
While patients who are overtly suicidal or have attempted self-harm are often quite apparent, each patient with depression should be assessed for risk of suicide. Consider suicide as a possibility in single-vehicle road traffic collisions, pedestrians struck by automobiles, falls, shootings and stabbings.
There is no routine panel for “medical clearance.” All workup should be tailored to the patient’s presenting complaints and the ED evaluation. Consider pregnancy testing for patients of child bearing age, glucose in patients with altered mental status and tests to aid the management of poisonings such as an EKG in the suspicion of tricyclic antidepressant overdose, chemistry to asses acid-base disorders or specific drug levels. X-rays can be useful to identify foreign bodies and fractures.
Initial ED management should focus on ABCs and identifying immediate threat to life. Any poisonings or injuries should be treated appropriately. The patient should be provided a safe environment and should not be permitted to leave the ED before treatment and risk-assessment is completed. Be sure to document completely and to comply with local legal requirements whenever a patient is held for psychiatric evaluation.
MOMMAS2 Focused Psychiatric Assessment:
The mnemonic MOMMAS2 can assist in recalling the focused psychiatric assessment.
M: Memory long and short term
O: Orientation to person, place and time
M: Mood (a symptom), “How do you feel?” “Happy,” “Mad,” “Sad?”
M: Mentation Ask about hallucinations, delusions, paranoia
A: Affect (a sign), How does the patient act? What are the eye contact, speech and demeanor?
S: Speech Is it organized and logical or disorganized and tangential?
S: Suicidality Is there a plan, intent, objective, preparation and/or rehearsal?
A complete neurologic exam is essential and may be integrated into the acquisition of a psychiatric history. Try to have the patient offer all of the components of the MOMMAS2 assessment in the history. Patients will often discus the precipitating crisis event. Obtain collateral history
Health care providers are tasked with utilizing judgment to plan for patient care though we are unable to accurately predict whether an individual patient will commit suicide. Assessing risk factors for suicide can assist in making these decisions. Risk factors include: prior attempts, previous psychiatric history, family history of mental illness or suicide, signs of depression or substance abuse. Assess the lethality of the method of self-harm used. Document patient’s social situation and follow-up opportunities as a part of the acute suicide risk assessment.
Patients at lower risk for suicide include those with few significant risk factors, patients with a supportive home environment and reliable access to healthcare, younger females with “hesitation cuts” or non-lethal ingestions, and those who assert a strong wish to live. Patients who commit to return if anything worsens and have specific follow-up in 48 hours also are at lower risk for suicide. While females attempt suicide more frequently than men, males are four times more likely to successfully commit suicide and tend to utilize violent methods.
Risk assessment is difficult because it relies on patient reported information in cases where they may not respond entirely truthfully and a majority of patients in one study denied suicidal intent in their last verbal communications although they ultimately died by suicide. Also, because suicide is a relatively low frequency event within a population the positive predictive values for even the best instruments will be low. This results in false positives, or patients deemed high risk and utilizing high-cost resources that may not be required. Many traditional risk assessment scales were never tested for validity though they may be useful in remembering common risk factors. Current research is focused on developing new scales empirically and deriving new evidence-based methods for risk assessment.
There are many national and international guidelines that vary on how to stratify risk and admission criteria; however, all stress the importance of identifying risk factors and opportunities for support and understanding the current degree of suicidal intent and they offer recommendations for intervention. Local policies and available resources will guide the usual disposition of patients presenting to the Emergency Department with suicidal thoughts. Physicians and treatment teams should familiarize themselves with local norms while developing appropriate, individualized plans for each patient.
Suicide precautions must be maintained from the time of arrival until care is complete for high-risk patients. This includes constant observation and removing any dangerous items from the room (including cords and sharps). These precautions must be maintained on the ward if admitted for management of intoxication or injury and until psychiatric treatment is complete. There are 3 options to obtain psychiatric evaluation: voluntary admission, involuntary psychiatric admission and discharge with close outpatient psychiatric follow-up.
An involuntary psychiatric admission is utilized in a patient who is determined to be at high-risk for suicide but who refuses to undergo psychiatric admission for evaluation and treatment. Procedures vary from state to state and local protocol must be observed, but in all cases a health care provider signs an initial certificate stating the need to hold the patient for psychiatric evaluation and treatment due to the potential for risk of harm to the patient or others if the mental illness remains untreated. Typically, this allows a 72-hour hold to allow for formal psychiatric evaluation to occur. If transfer is required to a psychiatric facility, it should be via EMS, never with family or friends in a private vehicle.
In patients not admitted, it is essential to establish that they are medically stable without evidence of intoxication or delirium prior to discharge. There should be no immediate risk of self-harm and the patient should agree to return for any new concerns. There should be a plan for treatment identified and any weapons or other methods of self-harm removed from the patient’s situation. A plan to attempt to resolve any issues precipitating the crisis should be developed and both physician and patient’s social supports should be in agreement with the discharge plan. Often providers discuss a “contract for safety” to ensure the patient promises not to commit suicide and will seek help if he or she has further suicidal thoughts; however, there is no evidence that this is an effective means of preventing suicide.
Pearl and Pitfalls
Ask directly about suicidal thoughts. It does not increase risk of suicide occurring and many patients are hesitant to offer this information if not asked.
Utilize collateral history.
Attempt to involve family and friends to ensure safe follow-up for any patients discharged.
Ensure discharged patients have a follow-up plan and will return for any increase in suicidal thoughts.
Elderly men with access to guns are a group at extremely high risk of suicide.
Failure to maintain appropriate suicide precautions in ED and throughout admission on medical and psychiatric wards.
Giving patients access to means to hurt themselves either in the ED or in the form of a prescription with a toxic number of tablets dispensed.
Failure to comply with local legal requirements for documentation when subjecting a patient to involuntary psychiatric evaluation or restraint.
In a complete history and physical exam, the patient describes increasing feelings of helplessness in his social and professional life. He has been afraid to ask for help but has thought of suicide often over the last 10 years. He has no other medical complaints and his physical exam was unremarkable. His brother reports by telephone that their mother had a long history of depression and corroborates the patient’s denial of any drugs or prescription medicines in the home. After medical clearance, the patient is referred to psychiatry for admission.
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